Future of Multimorbidity Research: How Should Understanding of Multimorbidity Inform Health System Design?

Prevalence and predictors of polypharmacy and comorbidities among patients with chronic obstructive pulmonary disease: a cross-sectional retrospective study in a tertiary hospital in Saudi Arabia

OBJECTIVE

This study aimed to determine the prevalence of polypharmacy, comorbidities and to investigate factors associated with polypharmacy among adult patients with Chronic Obstructive Pulmonary Disease (COPD).

METHODS

This was a retrospective single-centre cross-sectional study. Patients with a confirmed diagnosis of COPD according to the GOLD guidelines between 28 February 2020 and 1 March 2023 were included in this study. Patients were excluded if a pre-emptive diagnosis of COPD was made clinically without spirometry evidence of fixed airflow limitation. Population characteristics were presented as frequency for categorical variable. Logistic regression analysis was used to identify predictors of polypharmacy.

RESULTS

The study sample included a total of 705 patients with COPD. Most of the study sample were males (60%). The mean age of the study population was 65 years old. The majority of the study population had comorbid diseases (68%), hypertension and diabetes were the most common co-existent diseases. Around 55% of the study sample had polypharmacy. Females were significantly less likely to be on polypharmacy compared to males (OR = 0.68, 95% CI = [0.50-0.92], P-value = 0.012)). On the other hand, older patients aged 65.4 or more (OR = 2.31, 95% CI = [1.71-3.14], P-value ≤ 0.001), those with high BMI (≥ 29.2) (OR = 1.42, 95% CI = [1.05-1.92], P-value = 0.024), current smokers (OR = 1.9, 95% CI = [1.39-2.62], P-value ≤ 0.001), those who are receiving home care (OR = 5.29, 95% CI = [2.46-11.37], P-value ≤ 0.001), those who have comorbidities (OR = 19.74, 95% CI = [12.70-30.68], P-value ≤ 0.001) were significantly more likely to be on polypharmacy (p ≤ 0.05).

CONCLUSIONS

Polypharmacy is common among patients with COPD. Patients with high BMI, previous ICU hospitalization and older age are more likely to have polypharmacy. Future analytical studies are warranted to investigate outcomes in patients with COPD and polypharmacy.

Accepting multiple conditions in psychiatry: From comorbidity to multimorbidity

The concept of multimorbidity in psychiatry refers to the coexistence of multiple health conditions without conceptualizing a central disorder referring to a patient-centered approach that views every diagnosis equally. It emphasizes a shift from focusing on an index disorder to considering interrelated symptoms crucial in psychiatry due to frequent multimorbidity patterns. In clinical practice, multimorbidity guides patient-centered care helping to address the holistic needs of patients and challenging the organization of mental health care. In research, multimorbidity reshapes study outcomes and promotes the development of patient-reported outcome questionnaires, also posing ethical challenges and advocating for the inclusion of multimorbid patients in personalized interventions. Finally, multimorbidity in psychiatry has public health implications aligning with the socioecological systems perspective. This notion aims to improve prognosis, care, and health costs while impacting global mortality and challenging the conceptualization and organization of psychiatric care.

KNUST aging and human immunodeficiency virus outcomes-Study protocol

INTRODUCTION

Globally, 7 million people with HIV (PWH) aged over 50 years exist. 5 million of them live in sub-Saharan Africa, the epicenter of the HIV epidemic. In Ghana, every 1 in 6 PWH is aged over 50 years. However, access to geriatric health care is grossly limited in Ghana and the sub-Saharan Africa region. This has resulted in a lack of focus on geriatric syndromes, a multi-factorial clinical condition common in older PWH, that do not fit discrete disease categories. Consequently, this gap threatens the life expectancy for aging PWH, necessitating the need to promptly fill it. The KNUST Aging and HIV Outcomes (KAHO) study will help identify priorities and opportunities for developing an effective integrated model of HIV and geriatric healthcare in Ghana.

METHODS AND ANALYSIS

The KAHO study will recruit 151 PWH aged 50 years and older at the Infectious Disease Unit (IDU) of the University Hospital, Kwame Nkrumah University of Science and Technology (KNUST). The study will be conducted over a 2-year period and participants will be seen at months 0, 6 and 12. Participants at each visit will be taken through assessments and questionnaires on geriatric health, cognition, social vulnerability, HIV-related conditions and they will provide biospecimens for laboratory testing. We will also conduct semi-structured qualitative interviews of PWH, healthcare providers, policy makers and study research assistants. Quantitative data will be analyzed using one sample proportion test and linear regression models appropriately. The Levesque's framework will be used as a guide to analyze qualitative data.

Risk and protective factors of asthma and mental health condition multimorbidity in a national sample of Canadian children

BACKGROUND

The coexistence of childhood asthma and mental health (MH) conditions can impact management and health outcomes but we need to better understand the etiology of multimorbidity. We investigated the association between childhood asthma and MH conditions as well as the determinants of their coexistence.

METHODS

We used data from the Canadian Health Survey of Children and Youth 2019 (3-17 years; n = 47,871), a cross-sectional, nationally representative Statistics Canada dataset. Our primary outcome was condition status (no asthma or MH condition; asthma only; MH condition only; both asthma, and a MH condition (AMHM)). Predictors of condition status were assessed using multiple multinomial logistic regression. Sensitivity analyses considered individual MH conditions.

RESULTS

MH condition prevalence was almost two-fold higher among those with asthma than those without asthma (21.1% vs. 11.6%, respectively). There were increased risks of each condition category associated with having allergies, other chronic conditions, and family members smoking in the home while there were protective associations with each condition status category for being female and born outside of Canada. Four additional variables were associated with AMHM and MH condition presence with one additional variable associated with both AMHM and asthma. In sensitivity analyses, the associations tended to be similar for most characteristics, although there was some variability.

CONCLUSION

There are common risk factors of asthma and MH conditions along with their multimorbidity with a tendency for MH risk factors to be associated with multimorbidity. MH condition presence is common and important to assess among children with asthma.

How to incorporate chronic health conditions in oncologic decision-making and care for older patients with cancer? A survey among healthcare professionals

PURPOSE

A substantial proportion of patients with cancer are older and experience multimorbidity. As the population is ageing, the management of older patients with multimorbidity including cancer will represent a significant challenge to current clinical practice.

METHODS

This study aimed to (1) identify which chronic health conditions may cause change in oncologic decision-making and care in older patients and (2) provide guidance on how to incorporate these in decision-making and care provision of older patients with cancer. Based on a scoping literature review, an initial list of prevalent morbidities was developed. A subsequent survey among healthcare providers involved in the care for older patients with cancer assessed which chronic health conditions were relevant and why.

RESULTS

A list of 53 chronic health conditions was developed, of which 34 were considered likely or very likely to influence decision-making or care according to the 39 healthcare professionals who responded. These conditions were further categorized into five patient profiles. From these conditions, five patient profiles were developed, namely, (1) a somatic profile consisting of cardiovascular, metabolic, and pulmonary disease, (2) a functional profile, including conditions that cause disability, dependency or a high caregiver burden, (3) a psychosocial profile, including cognitive impairment, (4) a nutritional profile also including digestive system diseases, and finally, (5) a concurrent cancer profile. All profiles were considered likely to impact decision-making with differences between treatment modalities. The impact on the care trajectory was generally considered less significant, except for patients with care dependency and psychosocial health problems.

CONCLUSIONS

Chronic health conditions have various ways of influencing oncologic decision-making and the care trajectory in older adults with cancer. Understanding why specific chronic health conditions may impact the oncologic care trajectory can aid clinicians in the management of older patients with multimorbidity, including cancer.

Transition of care in a Danish context: translation, cross-cultural adaptation and content validation of CTM-15 and PACT-M

BACKGROUND

Transition of care from hospitalisation to home is a complex process with potential patient safety risks, especially for patients with multimorbidity. Traditionally, the quality of transition of care has been evaluated primarily through readmission rates. However, interpreting the readmission rates presents challenges, and readmission rates fail to capture the patient's perspective on the quality of the care transition. Insight into the patient's experience with their care or a health service can be provided through the use of patient-reported experience measures (PREMs), and the two PREMs Care Transitions Measure 15 (CTM-15) and Partners at Care Transitions Measure part 1 and 2 (PACT-M1 and PACT-M2) assess on the quality of transition of care from the patients' perspective. The aim of this study was to translate, culturally adapt, and assess content validity of CTM-15, PACT-M1, and PACT-M2 for Danish-speaking patients with multimorbidity.

METHODS

A two-step approach was used for content validation, involving cognitive debriefing and interviews with patients, representing the target group, as well as quantitative data collection from healthcare professionals representing all three sectors of the Danish healthcare system. The patients were systematically interviewed regarding the aspects of content validity; comprehensibility, relevance, and comprehensiveness. The healthcare professionals assessed the relevance and comprehensiveness of each item through questionnaires, allowing the calculation of a content validity index (CVI). An item CVI ≥ 0.78 is considered good.

RESULTS

The results of the qualitative data indicated that both CTM-15 and the PACT-M questionnaires were considered relevant, and comprehensible, and comprehensive to the target group. The CVI computed at item level determined that PACT-M1 and PACT-M2 demonstrated excellent content validity among the healthcare professionals, whereas the CVI for two items of the CTM-15 fell below the threshold value for "good".

CONCLUSION

The Danish versions of the PACT-M questionnaires demonstrated good content validity, and the CTM-15 demonstrated acceptable content validity based on qualitative data from patients and quantitative data from healthcare professionals. Further validation of the questionnaires, by assessing their construct validity and reliability is recommended.

Prediction of pharmaceutical and non-pharmaceutical expenditures associated with Diabetes Mellitus type II based on clinical risk

OBJECTIVE

To assess the effectiveness of different machine learning models in estimating the pharmaceutical and non-pharmaceutical expenditures associated with Diabetes Mellitus type II diagnosis, based on the clinical risk index determined by the analysis of comorbidities.

MATERIALS AND METHODS

In this cross-sectional study, we have used data from 11,028 anonymized records of patients admitted to a high-complexity hospital in Bogota, Colombia between 2017-2019 with a primary diagnosis of Diabetes. These cases were classified according to Charlson's comorbidity index in several risk categories. The main variables analyzed in this study are hospitalization costs (which include pharmaceutical and non-pharmaceutical expenditures), age, gender, length of stay, medicines and services consumed, and comorbidities assessed by the Charlson's index. The model's dependent variable is expenditure (composed of pharmaceutical and non-pharmaceutical expenditures). Based on these variables, different machine learning models (Multivariate linear regression, Lasso model, and Neural Networks) were used to estimate the pharmaceutical and non-pharmaceutical expenditures associated with the clinical risk classification. To evaluate the performance of these models, different metrics were used: Mean Absolute Percentage Error (MAPE), Mean Squared Error (MSE), Root Mean Squared Error (RMSE), Mean Absolute Error (MAE), and Coefficient of Determination (R2).

RESULTS

The results indicate that the Neural Networks model performed better in terms of accuracy in predicting pharmaceutical and non-pharmaceutical expenditures considering the clinical risk based on Charlson's comorbidity index. A deeper understanding and experimentation with Neural Networks can improve these preliminary results, therefore we can also conclude that the main variables used and those that were proposed can be used as predictors for the medical expenditures of patients with diabetes type-II.

CONCLUSIONS

With the increase of technology elements and tools, it is possible to build models that allow decision-makers in hospitals to improve the resource planning process given the accuracy obtained with the different models tested.

Cigarettes and e-cigarettes use among US adults with multimorbidity

Background

Tobacco use leads to multiple illnesses. Yet, the effects of different categories of tobacco use on multimorbidity remain understudied. We investigated the associations between tobacco use categories and multimorbidity and the potential moderating effects of age, sex, or race/ethnicity among adults in the United States.

Methods

We conducted a cross-sectional analysis using pooled data from the Behavioral Risk Factor Surveillance System for the years 2020-2022. Multimorbidity was ascertained through self-reported ≥2 chronic health conditions. We categorized tobacco use into nine derived from nonuse (did not use e-cigarettes or cigarettes), former cigarette or e-cigarette use, current (used on some days/everyday) cigarette use or e-cigarette use, or both (dual use). We used multinomial logistic regression to investigate the associations while accounting for potential confounding factors.

Results

Within the sample (N=1,080,257), 28.2% reported multimorbidity. For the categories examined (former exclusive e-cigarette, exclusive e-cigarette, former exclusive cigarette, former dual, former cigarette/current e-cigarette, exclusive cigarette, current cigarette/former e-cigarette and dual use), all reported higher odds of having multimorbidity compared to those who reported nonuse of both e-cigarettes and cigarettes. We found significant interactions for age, sex and race/ethnicity with the tobacco use categories for multimorbidity (p<0.01), where stronger associations were observed among younger adults, females and non-Hispanic Multiracial for current dual use (p<0.05).

Conclusions

The use of cigarettes, e-cigarettes, or both was associated with multimorbidity among adults, which was more pronounced among younger adults, females and non-Hispanic Multiracial. These findings underscore the importance of implementing targeted public health interventions to mitigate the health risks associated with using both products, particularly among specific demographics, to reduce the prevalence of multimorbidity.

Application of Machine Learning in Multimorbidity Research: Protocol for a Scoping Review

BACKGROUND

Multimorbidity, defined as the coexistence of multiple chronic conditions, poses significant challenges to health care systems on a global scale. It is associated with increased mortality, reduced quality of life, and increased health care costs. The burden of multimorbidity is expected to worsen if no effective intervention is taken. Machine learning has the potential to assist in addressing these challenges since it offers advanced analysis and decision-making capabilities, such as disease prediction, treatment development, and clinical strategies.

OBJECTIVE

This paper represents the protocol of a scoping review that aims to identify and explore the current literature concerning the use of machine learning for patients with multimorbidity. More precisely, the objective is to recognize various machine learning models, the patient groups involved, features considered, types of input data, the maturity of the machine learning algorithms, and the outcomes from these machine learning models.

METHODS

The scoping review will be based on the guidelines of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). Five databases (PubMed, Embase, IEEE, Web of Science, and Scopus) are chosen to conduct a literature search. Two reviewers will independently screen the titles, abstracts, and full texts of identified studies based on predefined eligibility criteria. Covidence (Veritas Health Innovation Ltd) will be used as a tool for managing and screening papers. Only studies that examine more than 1 chronic disease or individuals with a single chronic condition at risk of developing another will be included in the scoping review. Data from the included studies will be collected using Microsoft Excel (Microsoft Corp). The focus of the data extraction will be on bibliographical information, objectives, study populations, types of input data, types of algorithm, performance, maturity of the algorithms, and outcome.

RESULTS

The screening process will be presented in a PRISMA-ScR flow diagram. The findings of the scoping review will be conveyed through a narrative synthesis. Additionally, data extracted from the studies will be presented in more comprehensive formats, such as charts or tables. The results will be presented in a forthcoming scoping review, which will be published in a peer-reviewed journal.

CONCLUSIONS

To our knowledge, this may be the first scoping review to investigate the use of machine learning in multimorbidity research. The goal of the scoping review is to summarize the field of literature on machine learning in patients with multiple chronic conditions, highlight different approaches, and potentially discover research gaps. The results will offer insights for future research within this field, contributing to developments that can enhance patient outcomes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/53761.

Prevalence of multimorbidity and polypharmacy among adults and older adults: a systematic review

Multimorbidity (multiple conditions) and polypharmacy (multiple medications) are increasingly common, yet there is a need to better understand the prevalence of co-occurrence. In this systematic review, we examined the prevalence of multimorbidity and polypharmacy among adults (≥18 years) and older adults (≥65 years) in clinical and community settings. Six electronic databases were searched, and 87 studies were retained after two levels of screening. Most studies focused on adults 65 years and older and were done in population-based community settings. Although the operational definitions of multimorbidity and polypharmacy varied across studies, consistent cut-points (two or more conditions and five or more medications) were used across most studies. In older adult samples, the prevalence of multimorbidity ranged from 4·8% to 93·1%, while the prevalence of polypharmacy ranged from 2·6% to 86·6%. High heterogeneity between studies indicates the need for more consistent reporting of specific lists of conditions and medications used in operational definitions.

Multiple cardiovascular risk factor care in 55 low- and middle-income countries: A cross-sectional analysis of nationally-representative, individual-level data from 280,783 adults

The prevalence of multiple age-related cardiovascular disease (CVD) risk factors is high among individuals living in low- and middle-income countries. We described receipt of healthcare services for and management of hypertension and diabetes among individuals living with these conditions using individual-level data from 55 nationally representative population-based surveys (2009-2019) with measured blood pressure (BP) and diabetes biomarker. We restricted our analysis to non-pregnant individuals aged 40-69 years and defined three mutually exclusive groups (i.e., hypertension only, diabetes only, and both hypertension-diabetes) to compare individuals living with concurrent hypertension and diabetes to individuals with each condition separately. We included 90,086 individuals who lived with hypertension only, 11,975 with diabetes only, and 16,228 with hypertension-diabetes. We estimated the percentage of individuals who were aware of their diagnosis, used pharmacological therapy, or achieved appropriate hypertension and diabetes management. A greater percentage of individuals with hypertension-diabetes were fully diagnosed (64.1% [95% CI: 61.8-66.4]) than those with hypertension only (47.4% [45.3-49.6]) or diabetes only (46.7% [44.1-49.2]). Among the hypertension-diabetes group, pharmacological treatment was higher for individual conditions (38.3% [95% CI: 34.8-41.8] using antihypertensive and 42.3% [95% CI: 39.4-45.2] using glucose-lowering medications) than for both conditions jointly (24.6% [95% CI: 22.1-27.2]).The percentage of individuals achieving appropriate management was highest in the hypertension group (17.6% [16.4-18.8]), followed by diabetes (13.3% [10.7-15.8]) and hypertension-diabetes (6.6% [5.4-7.8]) groups. Although health systems in LMICs are reaching a larger share of individuals living with both hypertension and diabetes than those living with just one of these conditions, only seven percent achieved both BP and blood glucose treatment targets. Implementation of cost-effective population-level interventions that shift clinical care paradigm from disease-specific to comprehensive CVD care are urgently needed for all three groups, especially for those with multiple CVD risk factors.

The relationship between health literacy and health-related quality of life in Chinese older adults: a cross-sectional study

Background

This study aimed to examine the relationship between health literacy and health-related quality of life in older adults.

Methods

A cross-sectional survey design was used. We used a self-administered questionnaire to assess sociodemographic factors of older adults, the Chinese Citizen Health Literacy Questionnaire (HLQC) and the 36-item Chinese version of the Short Form 36 (SF-36) to measure health literacy and quality of life, respectively, among older adults. Between September 2011 and June 2012, information was collected from 1,396 older adults in 44 nursing homes in four cities through face-to-face interviews.

Results

The mean health literacy level of older adults in nursing homes was relatively low (71.74 ± 28.35). Health-related quality of life scores were moderate (104.77 ± 16.92). There were statistically significant differences in the effects of health literacy, education level, former occupation (professional), marital status (widowed) and race on health-related quality of life.

Conclusion

Improving health literacy is considered an important intervention to promote health-related quality of life in older adults in nursing homes.

Prevalence of and factors associated with multimorbidity among adults in Kuwait

BACKGROUND

This cross-sectional study aimed to assess the prevalence of morbidity i.e., one morbidity and multimorbidity (≥ 2 morbid conditions) among adults in Kuwait and to examine the sociodemographic and lifestyle factors associated with morbidity as a multinomial outcome in the study population.

METHODS

The data were collected from January 26, 2021, to February 3, 2021, using an electronic questionnaire, which was distributed on social media platforms. The consent form was attached with the questionnaire and the participants were requested to sign the consent form before completing the questionnaire. The prevalences (%) of each morbidity and multimorbidity were computed. Multivariable polychotomous logistic regression analysis was used to evaluate the association between the demographic and lifestyle factors with morbidity as a multinomial outcome.

RESULTS

Of 3572 respondents included, 89% were Kuwaiti, 78.3% females and 66% were 21- 40 years old. The prevalence of multimorbidity and one morbidity respectively was 27.4% and 29.7%. The prevalence of multimorbidity with two, three, four or five ill-health conditions were 14.3%, 7.4%, 3.5%, and 1.2%, respectively. A higher prevalence of multimorbidity was among respondents over 60 years of age (71%) and Kuwaiti nationals (28.9%). The final multivariable polychotomous logistic regression model revealed that age, sex, nativity, sedentary lifestyle, smoking, and alcohol drinking were significantly (p < 0.05) associated with multimorbidity. However, age and alcohol drinking were significant (p < 0.05) predictors of one morbidity.

CONCLUSION

This study provides evidence that multimorbidity is more prevalent among the elderly, females, and Kuwaiti nationals. Sedentary behaviour, smoking and alcohol consumption were significantly and independently associated with multimorbidity. These findings highlight the burden of multimorbidity and should be considered in the development of future prevention programs.

Associations of multimorbidity with body pain, sleep duration, and depression among middle-aged and older adults in China

BACKGROUND

Multimorbidity, body pain, sleep disturbance, and depression are major clinical and public health challenges. This paper aimed to examine the associations of multimorbidity with body pain, sleep duration, and depression; and whether the associations varied by socioeconomic status.

METHODS

Data was derived from four waves of the nationally representative China Health and Retirement Longitudinal Study (CHARLS), including participants aged 45 years and older in 2011. 12 physical non-communicable diseases and 1 mental chronic disease were used to measure multimorbidity. Educational attainment and annual per-capita household consumption expenditure were employed as proxies for socioeconomic status.

RESULTS

Of the 16,931 participants aged 45 + years old, the proportion of people with multimorbidity was 37.87% at baseline. The number of multimorbidity increased with older age and higher socioeconomic status. Multimorbidity was associated with more body pain (incidence rate ratio (IRR) = 1.53, 95% CI = 1.45-1.61), and decreased sleep duration (β = -0.26, 95% CI = -0.36--0.15). Furthermore, multimorbidity was associated with increased depression risks (odds ratio (OR) = 1.54, 95% CI = 1.44-1.64, adjusted for sociodemographic variables), with the mediating effects of the number of body pain and sleep duration. The associations between multimorbidity and depression persisted among different socioeconomic groups.

CONCLUSIONS

Multimorbidity was associated with increased body pain, decreased sleep duration, and further led to increased depression risks. It is necessary to pay attention to the multimorbidity of middle-aged and older adults, relieve their body pain, guarantee sufficient sleep, so as to reduce depression risks.

Subjective memory complaints and medication adherence among hypertensive Korean older adults with multimorbidity: mediating effect of depression and social support

BACKGROUND & AIM(S)

Medication adherence (MA) is a key factor in maintaining adequate blood pressure and preventing complications. However, some older adults experience difficulties in taking medicine properly due to declines in cognitive function. Although subjective memory complaints (SMC) are recognized as early markers of cognitive impairment, previous studies concerning the relationship between MA and cognitive function have focused only on objective cognitive function. Furthermore, while depression has a high correlation with SMC, low MA, and social support, there is limited evidence on their relationship. This study aims to understand the effect of SMC on MA and the mediating effect of depression and social support.

METHOD(S)

This study is a descriptive cross-sectional investigation. A sample of 195 community-dwelling hypertensive older adults with multimorbidity from 3 community senior centers in Gwangju, South Korea were recruited through convenience sampling. Data was collected through face-to-face survey from January to March 2018. The PROCESS macro v4.2 program [Model 6] was used to analyze the mediating effect of depression and social support in the relationship between SMC and MA. Data analysis was performed using SPSS/WIN 26.0 and STATA MP 17.0.

RESULTS

The average MA was 6.74. There were significant differences in MA according to awareness of prescribed drugs, awareness of side effects, insomnia, and healthcare accessibility. SMC was positively correlated with depression, while social support and MA were negatively correlated. While depression was a significant mediator of the effect of SMC on MA, the mediating effect of social support was not significant. The multiple mediation effect of depression and social support was not significant.

CONCLUSION

The results suggest that medication management of older adults in community settings should be accompanied by a comprehensive health assessment of associated factors. Health professionals should explore strategies to improve memory as well as prevent and alleviate depression to increase MA among hypertensive older adults with multimorbidity.

Co-designing care for multimorbidity: a systematic review

BACKGROUND

The co-design of health care enables patient-centredness by partnering patients, clinicians and other stakeholders together to create services.

METHODS

We conducted a systematic review of co-designed health interventions for people living with multimorbidity and assessed (a) their effectiveness in improving health outcomes, (b) the co-design approaches used and (c) barriers and facilitators to the co-design process with people living with multimorbidity. We searched MEDLINE, EMBASE, CINAHL, Scopus and PsycINFO between 2000 and March 2022. Included experimental studies were quality assessed using the Cochrane risk of bias tool (ROB-2 and ROBINS-I).

RESULTS

We screened 14,376 reports, with 13 reports meeting the eligibility criteria. Two reported health and well-being outcomes: one randomised clinical trial (n = 134) and one controlled cohort (n = 1933). Outcome measures included quality of life, self-efficacy, well-being, anxiety, depression, functional status, healthcare utilisation and mortality. Outcomes favouring the co-design interventions compared to control were minimal, with only 4 of 17 outcomes considered beneficial. Co-design approaches included needs assessment/ideation (12 of 13), prototype (11 of 13), pilot testing (5 of 13) (i.e. focus on usability) and health and well-being evaluations (2 of 13). Common challenges to the co-design process include poor stakeholder interest, passive participation, power imbalances and a lack of representativeness in the design group. Enablers include flexibility in approach, smaller group work, advocating for stakeholders' views and commitment to the process or decisions made.

CONCLUSIONS

In this systematic review of co-design health interventions, we found that few projects assessed health and well-being outcomes, and the observed health and well-being benefits were minimal. The intensity and variability in the co-design approaches were substantial, and challenges were evident. Co-design aided the design of novel services and interventions for those with multimorbidity, improving their relevance, usability and acceptability. However, the clinical benefits of co-designed interventions for those with multimorbidity are unclear.

An Exploration of Methods to Resolve Inconsistent Self-Reporting of Chronic Conditions and Impact on Multimorbidity in the Canadian Longitudinal Study on Aging

OBJECTIVES

To quantify inconsistent self-reporting of chronic conditions between the baseline (2011-2015) and first follow-up surveys (2015-2018) in the Canadian Longitudinal Study on Aging (CLSA), and to explore methods to resolve inconsistent responses and impact on multimorbidity.

METHODS

Community-dwelling adults aged 45-85 years in the baseline and first follow-up surveys were included (n = 45,184). At each survey, participants self-reported whether they ever had a physician diagnosis of 35 chronic conditions. Identifiable inconsistent responses were enumerated.

RESULTS

32-40% of participants had at least one inconsistent response across all conditions. Illness-related information (e.g., taking medication) resolved most inconsistent responses (>93%) while computer-assisted software asking participants to confirm their inconsistent disease status resolved ≤53%. Using these adjudication methods, multimorbidity prevalence at follow-up increased by ≤1.6% compared to the prevalence without resolving inconsistent responses.

DISCUSSION

Inconsistent self-reporting of chronic conditions is common but may not substantially affect multimorbidity prevalence. Future research should validate methods to resolve inconsistencies.

Dual burden of chronic physical conditions and mental disorders: Findings from the Saudi National Mental Health Survey

Introduction

Comorbidities of mental disorders and chronic physical conditions are a common medical burden reported among Western countries. National estimates of such comorbidities among the general population of Arab countries like Saudi Arabia are unknown. This study examined the prevalence of lifetime chronic physical conditions among the Saudi general population with DSM-IV 12-month mental disorders, and the associations with disability in the Kingdom of Saudi Arabia (KSA).

Methods

The Saudi National Mental Health Survey, a cross-sectional household study - part of the World Mental Health (WMH) Survey Consortium - was conducted between 2013-2016 in the KSA, with 4,001 Saudi citizens aged 15-65 (response rate 61%). The World Health Organization Composite International Diagnostic Interview 3.0 was used to assess prevalence of lifetime chronic physical conditions and 12-month mental disorders; disability was measured in terms of days out of role.

Results

The prevalence of any comorbid 12-month mental disorder among those with chronic physical conditions was 24%. Major depressive disorder, social phobia, and adult separation anxiety disorder were the most common comorbid mental disorders across all chronic physical conditions. Gender, education, income, urbanicity, region, and employment were associated with the presence of any chronic physical condition. Respondents with mental / physical comorbidities had 2.97 days out of role (on average) in the last 30 days.

Conclusion

Comorbidities of mental disorders and chronic physical conditions are common among Saudis. National efforts are needed to increase awareness of such comorbidities among the general population, and develop prevention and treatment services tailored to the needs of individuals at-risk for comorbidities.

Multimorbidity in systemic lupus erythematosus in a population-based cohort: the lupus Midwest network

OBJECTIVES

To assess the prevalence and incidence of multimorbidity and the association with the SLICC/ACR damage index (SDI) among patients with systemic lupus erythematosus (SLE).

METHODS

Using prevalent and incident population-based cohorts of patients with SLE and their matched comparators, we assessed 57 chronic conditions. Chronic conditions were categorized as SDI-related or SDI-unrelated. Multimorbidity was defined as the presence of 2+ chronic conditions. Multimorbidity at prevalence and incidence/index was compared between cohorts using logistic regression. Cox models were used to examine development of multimorbidity after SLE incidence.

RESULTS

The prevalent cohort included 449 patients with established SLE on January 1, 2015. They were three times more likely to have multimorbidity compared with non-SLE comparators (OR 2.98, 95% CI 2.18-4.11). The incident cohort included 270 patients with new-onset SLE. At SLE incidence, patients with SLE were more likely to have multimorbidity than comparators (OR 2.27, 95% CI 1.59-3.27). After incidence, the risk of developing multimorbidity was 2-fold higher among patients with SLE than comparators (hazard ratio (HR) 2.11, 95% CI 1.59-2.80). Development of multimorbidity was higher in patients with SLE based on SDI-related (HR 2.91, 95% CI 2.17-3.88) and SDI-unrelated conditions (HR 1.73, 95% CI, 1.32-2.26).

CONCLUSION

Patients with SLE have a higher burden of multimorbidity, even before the onset of the disease. The risk disparity continues after SLE classification and is also seen in a prevalent SLE cohort. Multimorbidity is driven both by SDI-related and unrelated conditions.

Classification of patients with osteoarthritis through clusters of comorbidities using 633 330 individuals from Spain

OBJECTIVES

To explore clustering of comorbidities among patients with a new diagnosis of OA and estimate the 10-year mortality risk for each identified cluster.

METHODS

This is a population-based cohort study of individuals with first incident diagnosis of OA of the hip, knee, ankle/foot, wrist/hand or 'unspecified' site between 2006 and 2020, using SIDIAP (a primary care database representative of Catalonia, Spain). At the time of OA diagnosis, conditions associated with OA in the literature that were found in ≥1% of the individuals (n = 35) were fitted into two cluster algorithms, k-means and latent class analysis. Models were assessed using a range of internal and external evaluation procedures. Mortality risk of the obtained clusters was assessed by survival analysis using Cox proportional hazards.

RESULTS

We identified 633 330 patients with a diagnosis of OA. Our proposed best solution used latent class analysis to identify four clusters: 'low-morbidity' (relatively low number of comorbidities), 'back/neck pain plus mental health', 'metabolic syndrome' and 'multimorbidity' (higher prevalence of all studied comorbidities). Compared with the 'low-morbidity' cluster, the 'multimorbidity' cluster had the highest risk of 10-year mortality (adjusted hazard ratio [HR]: 2.19 [95% CI: 2.15, 2.23]), followed by the 'metabolic syndrome' cluster (adjusted HR: 1.24 [95% CI: 1.22, 1.27]) and the 'back/neck pain plus mental health' cluster (adjusted HR: 1.12 [95% CI: 1.09, 1.15]).

CONCLUSION

Patients with a new diagnosis of OA can be clustered into groups based on their comorbidity profile, with significant differences in 10-year mortality risk. Further research is required to understand the interplay between OA and particular comorbidity groups, and the clinical significance of such results.

Chronic disease multimorbidity and substance use among African American men: veteran-non-veteran differences

OBJECTIVES

The purpose of the study was to explore the extent to which prior military service may moderate the relationship between chronic disease multimorbidity and substance use among African American men in the United States.

DESIGN

Data for this cross-sectional study was downloaded from the 2016 -2019 United States (US) National Survey on Drug Use and Health. We estimated three survey-weighted multivariable logistic regression models, where use of each of the following substances served as the dependent variables: illicit drugs, opioids, and tobacco. Differences in these outcomes were examined along two primary independent variables: veteran status and multimorbidity (and an interaction term for these variables). We also controlled for the following covariates: age, education, income, rurality, criminal behavior, and religiosity.

RESULTS

From the 37,203,237 (weighted N) African American men in the sample, approximately 17% reported prior military service. Veterans with ≥ 2 chronic diseases had higher rates of illicit drug use (aOR = 1.37, 95% CI = 1.01, 1.87; 32% vs. 28%) than non-veterans with ≥ 2 chronic diseases. Non-veterans with one chronic disease had higher rates of tobacco use (aOR = 0.80, 95% CI = 0.69, 0.93; 29% vs. 26%) and opioid misuse (aOR = 0.49, 95% CI = 0.36, 0.67; 29% vs. 18%) than veterans with one chronic disease.

DISCUSSION

Chronic disease multi-morbidity appears to be a context in which African American veterans may be at greater risk for certain undesirable health behaviors than African American non-veterans and at lower risk for others. This may be due to exposure to trauma, difficulty accessing care, socio-environmental factors, and co-occurring mental health conditions. These complex interactions may contribute to higher rates of SUDs among African American veterans compared to African American non-veterans.

Race, everyday discrimination, and cognitive function in later life

Discrimination is pernicious in many ways, but there are inconsistent findings regarding whether it is harmful to cognitive function in later life. To address the inconsistency, we use two closely related concepts of everyday discrimination to predict cognitive trajectories in a diverse sample. Using data from the Health and Retirement Study (HRS), we examine whether the frequency of discrimination, measured at baseline with six questions, is related to poorer cognitive function and change in function over time (2008-2016). Age at baseline ranged from 53 to 100. Growth curve models of initial cognitive function and change in function were estimated. Everyday global discrimination was associated with poorer initial cognition and slower declines over time, and these relationships were not moderated by race and ethnicity. By contrast, the relationship between everyday racial discrimination and cognition was moderated by race: more frequent everyday racial discrimination was associated with better initial cognitive function among Black adults but not among Hispanic and White adults. Discrimination is a multifaceted concept, and specific types of discrimination manifest lower or higher cognitive function during later life for White, Black, and Hispanic adults.

Plasma carotenoids and risk of depressive symptomatology in a population-based cohort of older adults

BACKGROUND

As part of a healthy diet, higher carotenoid intakes have been associated with a reduced risk of depression, mainly in adults, while prospective studies on plasma carotenoids in older adults are lacking. The aim of this study was to assess the prospective association between plasma carotenoids and the risk of Depressive Symptomatology (DS) in older adults.

METHODS

The study sample was based on the Three-City cohort of adults aged 65y+ free from DS at enrollment in 1999. Plasma carotenoids were measured at baseline. DS was assessed every 2-3 years over 17 years and defined by a Center for Epidemiologic Studies-Depression Scale score ≥ 16 and/or by antidepressant use. The association between plasma carotenoids or carotenoid/lipids (cholesterol and triglycerides) ratio and the risk for DS was assessed through multiple random-effect logistic regression.

RESULTS

The study sample was composed of 1010 participants (mean age 74 y (±4.9), 58 % of women) followed-up during a median time of 13.4 years. Plasma zeaxanthin and ratios of zeaxanthin/lipids, lutein+zeaxanthin/lipids and β-carotene/lipids were independently associated with a significant reduced risk of DS over time (Odds ratio (OR) = 0.81, 95 % Confidence Interval (CI) [0.67;0.99], OR = 0.79 [0.67;0.98], OR = 0.79 [0.64;0.94] and OR = 0.80 [0.66;0.97] for +1 standard deviation of each exposure respectively).

LIMITATIONS

Plasma carotenoids were only available at study baseline.

CONCLUSION

Focusing on circulating carotenoids and considering lipids levels, the present results suggested an association between higher levels of plasma zeaxanthin, combined lutein+zeaxanthin and β-carotene and a decreased risk of DS over time in older adults.

Multimorbidity and complex multimorbidity in Brazilians with severe obesity

To investigate the prevalence of multimorbidity and complex multimorbidity and their association with sociodemographic and health variables in individuals with severe obesity. This is a baseline data analysis of 150 individuals with severe obesity (body mass index ≥ 35.0 kg/m2) aged 18-65 years. The outcomes were multimorbidity and complex multimorbidity. Sociodemographic, lifestyle, anthropometric and self-perceived health data were collected. Poisson multiple regression was conducted to identify multimorbidity risk factors. The frequency of two or more morbidities was 90.7%, three or more morbidities was 76.7%, and complex multimorbidity was 72.0%. Living with four or more household residents was associated with ≥ 3 morbidities and complex multimorbidity. Fair and very poor self-perceived health was associated with ≥ 2 morbidities, ≥ 3 morbidities and complex multimorbidity. A higher BMI range (45.0-65.0 kg/m2) was associated with ≥ 2 morbidities and ≥ 3 morbidities. Anxiety (82.7%), varicose veins of lower limbs (58.7%), hypertension (56.0%) were the most frequent morbidities, as well as the pairs and triads including them. The prevalence of multimorbidity and complex multimorbidity in individuals with severe obesity was higher and the risk for multimorbidity and complex multimorbidity increased in individuals living in households of four or more residents, with fair or poor/very poor self-perceived health and with a higher BMI.

Prospective associations between diet quality, dietary components, and risk of cardiometabolic multimorbidity in older British men

PURPOSE

Cardiometabolic multimorbidity (CMM) is a major public health challenge. This study investigated the prospective relationships between diet quality, dietary components, and risk of CMM in older British men.

METHODS

We used data from the British Regional Heart Study of 2873 men aged 60-79 free of myocardial infarction (MI), stroke, and type 2 diabetes (T2D) at baseline. CMM was defined as the coexistence of two or more cardiometabolic diseases, including MI, stroke, and T2D. Sourcing baseline food frequency questionnaire, the Elderly Dietary Index (EDI), which was a diet quality score based on Mediterranean diet and MyPyramid for Older Adults, was generated. Cox proportional hazards regression and multi-state model were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

During a median follow-up of 19.3 years, 891 participants developed first cardiometabolic disease (FCMD), and 109 developed CMM. Cox regression analyses found no significant association between baseline EDI and risk of CMM. However, fish/seafood consumption, a dietary component of the EDI score, was inversely associated with risk of CMM, with HR 0.44 (95% CI 0.26, 0.73) for consuming fish/seafood 1-2 days/week compared to less than 1 day/week after adjustment. Further analyses with multi-state model showed that fish/seafood consumption played a protective role in the transition from FCMD to CMM.

CONCLUSIONS

Our study did not find a significant association of baseline EDI with CMM but showed that consuming more fish/seafood per week was associated with a lower risk of transition from FCMD to CMM in older British men.

The relationship between sleep health and multimorbidity in community dwelling populations: Systematic review and global perspectives

Previous research has identified a relationship between sleep problems and multimorbidity, defined as the co-occurrence of two or more chronic health conditions in the same individual. This systematic review sought to summarize the literature on the association between sleep duration and quality and multimorbidity in adult community-dwelling populations. A comprehensive search of the PubMed, Embase and CINAHL databases identified studies published between January 1990 and January 2023. Studies were included if they focused on community-dwelling populations, used an observational design, measured sleep quality or duration, used multimorbidity as the main study outcome, and explored the relationship between sleep and multimorbidity. Two reviewers independently conducted study screening, data extraction, and bias assessments. Twenty-four cross-sectional and five prospective cohort studies met the inclusion criteria, with studies from 16 countries and two with cross-country comparisons, and a total participant number of 481,862. Overall, poorer sleep quality and sleep duration outside current recommendations were consistently associated with multimorbidity, though with varying strength. This association was present regardless of specific multimorbidity definitions from different studies. Definitions of sleep duration and quality were inconsistent across studies, possibly contributing to mixed evidence on the observed association. Most studies were cross-sectional, limiting the assessment of the temporal direction of association. Our results corroborate relationships between poor sleep and risk of multimorbidity in adult community-dwelling populations around the world. Examining this relationship may help increase public health awareness of sleep as a modifiable risk factor for the prevention of chronic disease and healthy aging.

Safeguarding survival: Older persons with multiple chronic conditions' unplanned readmission experiences: A mixed methods systematic review

AIMS AND OBJECTIVES

The aim of this study was to create a holistic understanding of the psychosocial processes of older persons with multiple chronic conditions' experience with unplanned readmission experiences within 30 days of discharge home and identify factors influencing these psychosocial processes.

DESIGN

Mixed methods systematic review.

DATA SOURCES

Six electronic databases (Ovid MEDLINE (R) All 1946-present, Scopus, CINAHL, Embase, PsychINFO and Web of Science).

REVIEW METHODS

Peer-reviewed articles published between 2010 and 2021 and addressed study aims (n = 6116) were screened. Studies were categorised by method: qualitative and quantitative. Qualitative data synthesis used a meta-synthesis approach and applied thematic analysis. Quantitative data synthesis used vote counting. Data (qualitative and quantitative) were integrated through aggregation and configuration.

RESULTS

Ten articles (n = 5 qualitative; n = 5 quantitative) were included. 'Safeguarding survival' described older persons' unplanned readmission experience. Older persons experienced three psychosocial processes: identifying missing pieces of care, reaching for lifelines and feeling unsafe. Factors influencing these psychosocial processes included chronic conditions and discharge diagnosis, increased assistance with functional needs, lack of discharge planning, lack of support, increased intensity of symptoms and previous hospital readmission experiences.

CONCLUSIONS

Older persons felt more unsafe as their symptoms increased in intensity and unmanageability. Unplanned readmission was an action older persons required to safeguard their recovery and survival.

RELEVANCE TO CLINICAL PRACTICE

Nurses play a critical role in assessing and addressing factors that influence older persons' unplanned readmission. Identifying older persons' knowledge about chronic conditions, discharge planning, support (caregivers and community services), changes in functional needs, intensity of symptoms and past readmission experiences may prepare older persons to cope with their return home. Focusing on their health-care needs across the continuum of care (community, home and hospital) will mitigate the risks for unplanned readmission within 30 days of discharge.

REPORTING METHOD

PRISMA guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution due to design.

The digitized chronic disease management model: scalable strategies for implementing standardized healthcare and big data analytics in Shanghai

Background

Chronic disease management (CDM) falls under production relations, and digital technology belongs to the realm of productivity. Production relations must adapt to the development of productivity. Simultaneously, the prevalence and burden of chronic diseases are becoming increasingly severe, leveraging digital technology to innovate chronic disease management model is essential.

Methods

The model was built to cover experts in a number of fields, including administrative officials, public health experts, information technology staff, clinical experts, general practitioners, nurses, metrologists. Integration of multiple big data platforms such as General Practitioner Contract Platform, Integrated Community Multimorbidity Management System and Municipal and District-Level Health Information Comprehensive Platform. This study fully analyzes the organizational structure, participants, service objects, facilities and equipment, digital technology, operation process, etc., required for new model in the era of big data.

Results

Based on information technology, we build Integrated Community Multimorbidity Care Model (ICMCM). This model is based on big data, is driven by "technology + mechanism," and uses digital technology as a tool to achieve the integration of services, technology integration, and data integration, thereby providing patients with comprehensive people-centered services. In order to promote the implementation of the ICMCM, Shanghai has established an integrated chronic disease management information system, clarified the role of each module and institution, and achieved horizontal and vertical integration of data and services. Moreover, we adopt standardized service processes and accurate blood pressure and blood glucose measurement equipment to provide services for patients and upload data in real time. On the basis of Integrated Community Multimorbidity Care Model, a platform and index system have been established, and the platform's multidimensional cross-evaluation and indicators are used for management and visual display.

Conclusions

The Integrated Community Multimorbidity Care Model guides chronic disease management in other countries and regions. We have utilized models to achieve a combination of services and management that provide a grip on chronic disease management.

The worse we feel, the more intensively we need to stick together: a qualitative study of couples' emotional co-regulation of the challenge of multimorbidity

Introduction

Being faced with multimorbidity (i.e., being diagnosed with at least two chronic conditions), is not only demanding in terms of following complicated medical regimes and changing health behaviors. The changes and threats involved also provoke emotional responses in the patients but also in their romantic partners. This study aims at exploring the ways of emotional co-regulation that couples facing multimorbidity express when interviewed together.

Method

N = 15 opposite sex couples with one multimorbid patient after an acute health crisis that led to hospitalization were asked in a semi-structured interview about how they found ways to deal with the health situation, what they would recommend to other couples in a similar situation, and how they regulated their emotional responses. Interviews were analyzed qualitatively following open, axial, and selective coding, as in the grounded theory framework.

Results

Emerging categories from the romantic partners' and the patients' utterances revealed three main categories: First, overlapping cognitive appraisals about the situation (from fighting spirit to fatalism) and we-ness (construing the couple self as a unit) emerged as higher order factor from the utterances. Second, relationship-related strategies including strategies aimed at maintaining high relationship quality in spite of the asymmetric situation like strengthening the common ground and balancing autonomy and equity in the couple were often mentioned. Third, some couples mentioned how they benefit from individual strategies that involve fostering individual resources of the partners outside the couple relationship (such as cultivating relationships with grandchildren or going outdoors to nature).

Discussion

Results underline the importance of a dyadic perspective not only on coping with disease but also on regulating the emotional responses to this shared challenging situation. The utterances of the couples were in line with earlier conceptualizations of interpersonal emotion regulation and dyadic perspectives on we-disease. They broaden the view by integrating the interplay between individual and interpersonal regulation strategies and underline the importance of balancing individual and relational resources when supporting couples faced with chronic diseases.

Is tooth loss associated with multiple chronic conditions?

OBJECTIVES

To examine the relationship between tooth loss and co-occurrence of multiple chronic conditions (MCC) among American adults at working age.

MATERIALS AND METHODS

Data was from the Behavioural Risk Factor Surveillance System 2018, a cross-sectional telephone-based, nationally representative survey of American adults. We included participants aged 25-64 years. The survey included sociodemographic data, reported diagnosis of chronic conditions, the number of missing teeth and health behaviours. An aggregate variable of chronic conditions was created which included heart attack, angina, stroke, cancer, chronic pulmonary disease, diabetes, asthma, arthritis, depression, and kidney diseases. The association between the number of missing teeth and the aggregate of chronic conditions was assessed adjusting for confounders.

RESULTS

The analysis included 202,809 participants. The mean number of MCC was 0.86 (95% Confidence Interval 'CI':0.85,0.87). Tooth loss was significantly associated with MCC with rate ratio 1.18 (95% CI:1.15,1.21), 1.53 (95% CI:1.48,1.59) and 1.62 (95% CI:1.55,1.69) for those reporting losing 1-5 teeth, 6 or more but not all, and all teeth, respectively after adjusting for demographic, socioeconomic, and behavioural factors.

CONCLUSION

Tooth loss could be an early marker for the co-occurrence of multiple chronic conditions among adults of working age. The association could be attributed to common risk factors for oral and general health.

Chronic health conditions and mortality among older adults with complex care needs in Aotearoa New Zealand

BACKGROUND

Older people have more comorbidities than younger groups and multimorbidity will increase. Often chronic conditions affect quality of life, functional ability and social participation. Our study aim was to quantify the prevalence of chronic conditions over a three-year period and their association with mortality after accounting for demographics.

METHODS

We conducted a retrospective cohort study using routinely collected health data including community-dwelling older adults in New Zealand who had an interRAI Home Care assessment between 1 January 2017 and 31 December 2017. Descriptive statistics and differences between variables of interest among ethnic groups were reported. Cumulative density plots of mortality were developed. Logistic regression models adjusted for age and sex to estimate mortality were created independently for each combination of ethnicity and disease diagnosis.

RESULTS

The study cohort consisted of 31,704 people with a mean (SD) age of 82.3 years (8.0), and of whom 18,997 (59.9%) were female. Participants were followed for a median 1.1 (range 0 to 3) years. By the end of the follow-up period 15,678 (49.5%) people had died. Nearly 62% of Māori and Pacific older adults and 57% of other ethnicities had cognitive impairment. Diabetes the next most prevalent amongst Māori and Pacific peoples, and coronary heart disease amongst Non-Māori/Non-Pacific individuals. Of the 5,184 (16.3%) who had congestive heart failure (CHF), 3,450 (66.6%) died. This was the highest mortality rate of any of the diseases. There was a decrease in mortality rate with age for both sexes and all ethnicities for those with cancer.

CONCLUSIONS

Cognitive impairment was the most common condition in community dwelling older adults who had an interRAI assessment. Cardiovascular disease (CVD) has the highest mortality risk for all ethnic groups, and in non-Māori/non-Pacific group of advanced age, risk of mortality with cognitive impairment is as high as CVD risk. We observed an inverse for cancer mortality risk with age. Important differences between ethnic groups are reported.

Deprescribing Strategies: A Prospective Study on Proton Pump Inhibitors

Proton pump inhibitors (PPIs) are among the most controversially prescribed drugs in polypharmacy. This observational prospective study assessed the PPI prescriptive trend during hospitalization before and after implementation of a prescribing/deprescribing algorithm in a real-life hospital setting and the related clinical-economic benefit at discharge. PPI prescriptive trends were compared between three quarters of 2019 (9 months) and the same period of 2018 by a chi-square test with a Yate's correction. The proportions of treated patients in the two years (1120 discharged patients in 2018 and 1107 in 2019) were compared by the Cochran-Armitage trend test. DDDs (defined daily doses) were compared between 2018 and 2019 by the non-parametric Mann-Whitney test and normalizing DDD/DOT (days of therapy) and DDD/100 bd (bed days) for each patient. Multivariate logistic regression was performed on PPI prescriptions at discharge. The distribution of patients with PPIs at discharge was significantly different in the two years (p = 0.0121). There was a downward trend in the number of PPI prescriptions (29.9%) in the third trimester of 2019 compared to the others of the same year (first trimester: 34.1%, second trimester: 36.0%) and by contrast with the same periods of 2018 (29.4, 36.0, and 34.7%) (p = 0.0124). DDDs/patient did not differ between 2018 and 2019 nor across the three trimesters. However, both DDD/DOT and DDD/100 bd showed a decrease in the third trimester of 2019, with a marked difference for DDD/DOT (p = 0.0107). The reduction in consumption detected in the last phase of 2019 in terms of DDD/DOT was 0.09 with a consequent containment of pharmaceutical spending. The development and implementation of multidisciplinary prescribing/deprescribing protocols in both hospital and community settings could lead to a reduction in the misuse of PPIs, with significant savings in healthcare resources.

Longitudinal models for the progression of disease portfolios in a nationwide chronic heart disease population

BACKGROUND AND AIM

With multimorbidity becoming increasingly prevalent in the ageing population, addressing the epidemiology and development of multimorbidity at a population level is needed. Individuals subject to chronic heart disease are widely multimorbid, and population-wide longitudinal studies on their chronic disease trajectories are few.

METHODS

Disease trajectory networks of expected disease portfolio development and chronic condition prevalences were used to map sex and socioeconomic multimorbidity patterns among chronic heart disease patients. Our data source was all Danish individuals aged 18 years and older at some point in 1995-2015, consisting of 6,048,700 individuals. We used algorithmic diagnoses to obtain chronic disease diagnoses and included individuals who received a heart disease diagnosis. We utilized a general Markov framework considering combinations of chronic diagnoses as multimorbidity states. We analyzed the time until a possible new diagnosis, termed the diagnosis postponement time, in addition to transitions to new diagnoses. We modelled the postponement times by exponential models and transition probabilities by logistic regression models.

FINDINGS

Among the cohort of 766,596 chronic heart disease diagnosed individuals, the prevalence of multimorbidity was 84.36% and 88.47% for males and females, respectively. We found sex-related differences within the chronic heart disease trajectories. Female trajectories were dominated by osteoporosis and male trajectories by cancer. We found sex important in developing most conditions, especially osteoporosis, chronic obstructive pulmonary disease and diabetes. A socioeconomic gradient was observed where diagnosis postponement time increases with educational attainment. Contrasts in disease portfolio development based on educational attainment were found for both sexes, with chronic obstructive pulmonary disease and diabetes more prevalent at lower education levels, compared to higher.

CONCLUSIONS

Disease trajectories of chronic heart disease diagnosed individuals are heavily complicated by multimorbidity. Therefore, it is essential to consider and study chronic heart disease, taking into account the individuals' entire disease portfolio.

Implementation frameworks for polypharmacy management within healthcare organisations: a scoping review

BACKGROUND

Several guidelines support polypharmacy management in individual patients. More organisational-level focus is needed on the use of implementation frameworks.

AIM

To characterise the peer reviewed literature on implementation frameworks, focussing on barriers and facilitators to implementation at organisational level in the context of polypharmacy management.

METHOD

A scoping review protocol was devised, supporting retrieval of studies published in English, reporting from any sector of practice. Medline, International Pharmaceutical Abstracts, Cumulative Index of Nursing and Allied Health Literature and Business Source Complete were searched to January 2022 using Medical Subject Headings including: 'polypharmacy', 'deprescriptions', 'strategic planning' and 'organizational innovation'. A narrative approach to data synthesis was applied. Searching, data extraction and synthesis were undertaken independently by two reviewers.

RESULTS

After screening 797 records eight papers remained. Two were descriptive outlining details of specific initiatives, six used qualitative methods to explore determinants for implementation including barriers and enablers. Organisation level barriers included: poor organisational culture with a lack of sense of urgency and national plans, resource availability and communication issues including patient information and at transitions of care. Organisational facilitators included availability of government funding and regulatory environment promoting patient safety, a national emphasis on quality of care for older adults, co-ordinated national efforts and local evidence.

CONCLUSION

Limited literature focusses on the use of implementation frameworks at organisational levels. This review highlights the need for further work on implementation frameworks in this context to help achieve effective organisational change.

Components and Outcomes in Under- and Postgraduate Medical Education to Prepare for the Delivery of Integrated Care for the Elderly: A Scoping Review

Introduction

The ageing society requires physicians who can deliver integrated care, but it is unclear how they should be prepared for doing so. This scoping review aims to create an overview of educational programmes that prepare (future) physicians to deliver integrated care while addressing components and outcomes of the interventions.

Method

We included papers from five databases that contained: (1) integrated care (2) education programme (3) medical students (4) elderly, or synonyms. We divided the WHO definition of integrated care into ten components for the concept of 'integrated care'. Data were collected with a charting template, and template analysis was used to formulate themes.

Results

We found 17 educational programmes in different learning settings. All programmes addressed several components of the WHO definition. The programmes primarily focused on care for individual patients (micro-level), and the outcomes suggested that experiencing the complexity of care is key.

Conclusion

This review revealed the limited evidence on educational programmes about integrated care for the elderly. Our findings suggest that educational programmes on integrated care should not be limited to the micro-level, and that students should obtain adaptive expertise by experiencing complexity. Future research should contain an explicit description and definition of integrated care.

Can markers of disease severity improve the predictive power of claims-based multimorbidity indices?

BACKGROUND

Claims-based measures of multimorbidity, which evaluate the presence of a defined list of diseases, are limited in their ability to predict future outcomes. We evaluated whether claims-based markers of disease severity could improve assessments of multimorbid burden.

METHODS

We developed 7 dichotomous markers of disease severity which could be applied to a range of diseases using claims data. These markers were based on the number of disease-associated outpatient visits, emergency department visits, and hospitalizations made by an individual over a defined interval; whether an individual with a given disease had outpatient visits to a specialist who typically treats that disease; and ICD-9 codes which connote more versus less advanced or symptomatic manifestations of a disease. Using Medicare claims linked with Health and Retirement Study data, we tested whether including these markers improved ability to predict ADL decline, IADL decline, hospitalization, and death compared to equivalent models which only included the presence or absence of diseases.

RESULTS

Of 5012 subjects, median age was 76 years and 58% were female. For a majority of diseases tested individually, adding each of the 7 severity markers yielded minimal increase in c-statistic (≤0.002) for outcomes of ADL decline and mortality compared to models considering only the presence versus absence of disease. Gains in predictive power were more substantial for a small number of individual diseases. Inclusion of the most promising marker in multi-disease multimorbidity indices yielded minimal gains in c-statistics (<0.001-0.007) for predicting ADL decline, IADL decline, hospitalization, and death compared to indices without these markers.

CONCLUSIONS

Claims-based markers of disease severity did not contribute meaningfully to the ability of multimorbidity indices to predict ADL decline, mortality, and other important outcomes.

Development of a Person-Centred Integrated Care Approach for Chronic Disease Management in Dutch Primary Care: A Mixed-Method Study

To reduce the burden of chronic diseases on society and individuals, European countries implemented chronic Disease Management Programs (DMPs) that focus on the management of a single chronic disease. However, due to the fact that the scientific evidence that DMPs reduce the burden of chronic diseases is not convincing, patients with multimorbidity may receive overlapping or conflicting treatment advice, and a single disease approach may be conflicting with the core competencies of primary care. In addition, in the Netherlands, care is shifting from DMPs to person-centred integrated care (PC-IC) approaches. This paper describes a mixed-method development of a PC-IC approach for the management of patients with one or more chronic diseases in Dutch primary care, executed from March 2019 to July 2020. In Phase 1, we conducted a scoping review and document analysis to identify key elements to construct a conceptual model for delivering PC-IC care. In Phase 2, national experts on Diabetes Mellitus type 2, cardiovascular diseases, and chronic obstructive pulmonary disease and local healthcare providers (HCP) commented on the conceptual model using online qualitative surveys. In Phase 3, patients with chronic conditions commented on the conceptual model in individual interviews, and in Phase 4 the conceptual model was presented to the local primary care cooperatives and finalized after processing their comments. Based on the scientific literature, current practice guidelines, and input from a variety of stakeholders, we developed a holistic, person-centred, integrated approach for the management of patients with (multiple) chronic diseases in primary care. Future evaluation of the PC-IC approach will show if this approach leads to more favourable outcomes and should replace the current single-disease approach in the management of chronic conditions and multimorbidity in Dutch primary care.

The prevalence of cardiometabolic multimorbidity and its associations with health outcomes among women in China

Objective

In China, a limited number of studies focus on women and examine the effect of cardiometabolic multimorbidity (defined as the presence of two or more cardiometabolic diseases) on health outcomes. This research aims to investigate the epidemiology of cardiometabolic multimorbidity and the association of cardiometabolic multimorbidity with long-term mortality.

Methods

This study used data from the China Health and Retirement Longitudinal Study between 2011 and 2018, which includes 4,832 women aged 45 years and older in China. Poisson-distributed Generalized Linear Models (GLM) were applied to examine the association of cardiometabolic multimorbidity with all-cause mortality.

Results

Overall, the prevalence of cardiometabolic multimorbidity was 33.1% among the total sample of 4,832 Chinese women, and increased with age, ranging from 28.5% (22.1%) for those aged 45-54 years to 65.3% (38.2%) for those aged ≥75 years in urban (rural) areas. Compared with the group of none and single disease, cardiometabolic multimorbidity was positively associated with all-cause death (RR = 1.509, 95% CI = 1.130, 2.017), after adjusting socio-demographic and lifestyle behavioral covariates. Stratified analyses revealed that the association between cardiometabolic multimorbidity and all-cause death was only statistically significant (RR = 1.473, 95% CI = 1.040, 2.087) in rural residents, but not significant in urban residents.

Conclusion

Cardiometabolic multimorbidity is common among women in China and has been associated with excess mortality. Targeted strategies and people-centered integrated primary care models must be considered to more effectively manage the cardiometabolic multimorbidity shift from focusing on single-disease.

The clustering of physical health conditions and associations with co-occurring mental health problems and problematic alcohol use: a cross-sectional study

BACKGROUND

There is strong evidence for the co-occurrence of mental health conditions and alcohol problems, yet physical health outcomes among this group are not well characterised. This study aimed to identify clusters of physical health conditions and their associations with mental health and problematic alcohol use in England's general population.

METHODS

Cross-sectional analysis of the 2014 Adult Psychiatric Morbidity Survey (N = 7546) was conducted. The survey used standardised measures of problematic alcohol use and mental health conditions, including the Alcohol Use Disorders Identification Test (AUDIT) and the Clinical Interview Schedule-Revised. Participants self-reported any lifetime physical health conditions. Latent class analysis considered 12 common physical illnesses to identify clusters of multimorbidity. Multinomial logistic regression (adjusting for age, gender, ethnicity, education, and occupational grade) was used to explore associations between mental health, hazardous drinking (AUDIT 8 +), and co-occurring physical illnesses.

RESULTS

Five clusters were identified with statistically distinct and clinically meaningful disease patterns: 'Physically Healthy' (76.62%), 'Emerging Multimorbidity' (3.12%), 'Hypertension & Arthritis' (14.28%), 'Digestive & Bowel Problems'' (3.17%), and 'Complex Multimorbidity' (2.8%). Having a mental health problem was associated with increased odds of 'Digestive & Bowel Problems' (adjusted multinomial odds ratio (AMOR) = 1.58; 95% CI [1.15-2.17]) and 'Complex Multimorbidity' (AMOR = 2.02; 95% CI [1.49-2.74]). Individuals with co-occurring mental health conditions and problematic alcohol use also had higher odds of 'Digestive & Bowel Problems' (AMOR = 2.64; 95% CI [1.68-4.15]) and 'Complex Multimorbidity' (AMOR = 2.62; 95% CI [1.61-4.23]).

CONCLUSIONS

Individuals with a mental health condition concurrent with problematic alcohol use experience a greater burden of physical illnesses, highlighting the need for timely treatment which is likely to include better integration of alcohol and mental health services.

Evaluating the Effectiveness of Remote Behavioral Interventions Facilitated by Health Care Providers at Improving Medication Adherence in Cardiometabolic Conditions: A Systematic Review and Meta-Analysis

BACKGROUND

Although cardiometabolic conditions account for over 32% of all global deaths, nearly half of the patients with cardiometabolic conditions do not take medication as prescribed. Remote behavioral interventions have been shown to potentially improve adherence in these patients and further support cost effective clinical practice.

PURPOSE

To evaluate the effectiveness of remote behavioral interventions at improving treatment adherence and to explore behavioral intervention components associated with it.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science in April 2021. Random-effects meta-analyses were utilized.

RESULTS

In total, 40 studies, including 24,672 participants, were included. The overall quality of evidence, assessed using the RoB2 tool, was low. The intervention had a small (odds ratios [OR] = 1.70, 95% CI: 1.47, 1.96, N = 4823 p < .001) to moderate effect (SMD = 0.57, 95% CI: 0.38, 0.76, N = 20,271, p < .001) on the dichotomous and continuous outcomes, respectively. Systolic blood pressure (SBP) was reduced by 3.71 mmHg (95% CI: 3.99, 3.43, N = 6,527, p < .001) and participants receiving the intervention were twice more likely to achieve blood pressure (BP) control (OR = 2.14, 95% CI: 1.61, 2.84, N = 1,172, p < .001). Generally, HBA1c decreased by 0.25% (95% CI: 0.33, 0.17, N = 6,734, p < .001), whereas low-density lipoprotein (LDL)-cholesterol dropped by 6.82 mg/dL (95% CI: 8.33, 5.30, N = 4,550, p < .001) in favor of the intervention. There was a trend suggesting a potential positive effects on reducing visits to emergency department (OR=0.76, 95% CI: 0.57, 1.01, N = 4,182) and mortality rates (OR=0.78, 95% CI: 0.42, 1.42, N = 1,971), and no risk for hospital readmission (OR=1.00, 95% CI: 0.83, 1.20, N = 5,402), favoring the intervention.

CONCLUSIONS

Despite low quality of evidence, remote consultations are effective at improving medication adherence and clinical indicators, and potentially cost-effective solution for health care services.

An Intervention Program to Reduce Medication-Related Problems Among Polymedicated Home-Dwelling Older Adults (OptiMed): Protocol for a Pre-Post, Multisite, Pilot, and Feasibility Study

BACKGROUND

Effective medication management is one of the essential preconditions for enabling polymedicated home-dwelling older adults with multiple chronic conditions to remain at home and preserve their quality of life and autonomy. Lack of effective medication management predisposes older adults to medication-related problems (MRPs) and adverse health outcomes, which can lead to the degradation of a patient's acute clinical condition, physical and cognitive decline, exacerbation of chronic medical conditions, and avoidable health care costs. Nonetheless, it has been shown that MRPs can be prevented or reduced by using well-coordinated, patient-centered, interprofessional primary care interventions.

OBJECTIVE

This study aimed to explore the feasibility and acceptability of an evidence-based, multicomponent, interprofessional intervention program supported by informal caregivers to decrease MRPs among polymedicated home-dwelling older adults with multiple chronic conditions.

METHODS

This quasi-experimental, pre-post, multisite pilot, and feasibility study will use an open-label design, with participants knowing the study's objectives and relevant information, and it will take place in primary health care settings in Portugal and Switzerland. The research population will comprise 30 polymedicated, home-dwelling adults, aged ≥65 years at risk of MRPs and receiving community-based health care, along with their informal caregivers and health care professionals.

RESULTS

Before a projected full-scale study, this pilot and feasibility study will focus on recruiting and ensuring the active collaboration of its participants and on the feasibility of expanding this evidence-based, multicomponent, interprofessional intervention program throughout both study regions. This study will also be essential to projected follow-up research programs on informal caregivers' multiple roles, enhancing their coordination tasks and their own needs. Results are expected at the end of 2024.

CONCLUSIONS

Designing, establishing, and exploring the feasibility and acceptability of an intervention program to reduce the risks of MRPs among home-dwelling older adults is an underinvestigated issue. Doing so in collaboration with all the different actors involved in that population's medication management and recording the first effects of the intervention will make this pilot and feasibility study's findings very valuable as home care becomes an ever more common solution.

TRIAL REGISTRATION

Swiss National Clinical Trials Portal 000004654; https://tinyurl.com/mr3yz8t4.

A critical appraisal of professional competency frameworks: What guidance is provided for stroke rehabilitation clinicians managing 'complexity'?

Background

Given current health system trends, clinicians increasingly care for patients with complex care needs. There is a recognized lack of evidence to support clinician decision-making in these situations, as complex or multimorbid patients have been historically excluded from the types of research that inform clinical practice guidelines. However, expert clinicians at sites of excellence (e.g., Stroke Distinction sites) provide measurably excellent care. We sought to review profession-specific competency frameworks to locate information that may be supporting the development of clinician expertise when managing the care of patients with complex care needs.

Methods

We conducted a review of the professional competency frameworks for core members of the inpatient stroke rehabilitation team, to determine the degree of guidance and/or preparation for the management of patients with complex care needs. We developed and applied an assessment rubric to locate references to patient complexity, multimorbidity and complexity theory.

Results

Across the professional competency frameworks, there are some references to complexity at patient- and team-levels; there are fewer references to system-level complexity. We noted a lack of clear guidance for clinicians regarding the management of patients with complex care needs.

Conclusion

Further research is needed to explore how clinicians develop expertise in the management of patients with complex care needs, as we noted minimal guidance in the professional competency frameworks. However, we suggest that integrating complexity-related language into professional competency frameworks could better prime novice clinicians for new learning in the workplace and ease their transition into working in a complex context.

Comparing stroke rehabilitation inpatients and clinical trials eligibility criteria: A secondary chart review analysis revealing that most patients could have been excluded from rehabilitation trials based on comorbidity status

Background

The generalizability of treatments examined in rehabilitation randomized controls trials (RCTs) partly depend on the similarity between trial subjects and a stroke rehabilitation inpatient population. The aim of this study was to determine the proportion of stroke rehabilitation inpatients that would have been eligible or ineligible to participate in published stroke RCTs.

Methods

This was a secondary analysis of chart review data collected as part of an independent quality improvement initiative. Data pertaining to the characteristics of stroke rehabilitation inpatients (e.g. age, cognitive impairment, previous stroke, comorbidities) were extracted from the medical charts of patients consecutively admitted to an inpatient stroke rehabilitation unit at a large urban rehabilitation hospital in Canada. Using the exclusion criteria categories of stroke RCTs identified from a systematic scoping review of 428 RCTs, we identified how many stroke rehabilitation inpatients would have been eligible or ineligible to participate in stroke RCTs based on their age, cognitive impairment, previous stroke and presence of comorbidities.

Results

In total, 110 stroke rehabilitation inpatients were included. Twenty-four percent of patients were 80 years of age or older, 84.5% had queries or concerns regarding patient cognitive abilities, 28.0% had a previous stroke, and 31.8% had a severe stroke. Stroke rehabilitation inpatients had six comorbidities on average. Based on these factors, most stroke rehabilitation inpatients could have been excluded from stroke RCTs, with cognitive impairment the most common RCT exclusion criteria.

Conclusions

Changes to the design of RCTs would support the development of clinical practice guidelines that reflect stroke rehabilitation inpatient characteristics, enhancing equity, diversity, and inclusion within samples and the generalizability of results.

[Patients, Partners, Professionals, Payers and Policy Makers Preferences for Integrated Care for Multimorbidity in Germany: A Discrete Choice Experiment]

AIM OF THE WORK

The aim of this study was to measure and compare the relative importance that patients with multimorbidity, partners and other informal caregivers, professionals, payers and policy makers attribute to different outcome measures of integrated care (IC) programmes in Germany.

METHODS

A DCE was conducted, asking respondents to choose between two IC programmes for persons with multimorbidity. Each IC programme was presented by means of attributes or outcomes reflecting the Triple Aim. They were divided into the outcomes health/ wellbeing, experience with care and costs with in total eight attributes and three levels of performance.

RESULTS

The results of n=676 questionnaires showed that the attributes "enjoyment of life" and "continuity of care" received the highest ratings across all stakeholder groups. The lowest relative scores remained for the attribute "total costs" for all stakeholders. The preferences of professionals and informal caregivers differed most distinctly from the patients' preferences. The differences mostly concerned "physical functioning", which was rated highest by patients, and "person centeredness" and "continuity of care", which received the highest ratings from professionals.

CONCLUSIONS

The preference heterogeneities identified in relation to the outcomes of IC programmes between different stakeholders highlight the importance of informing professionals and policy makers about the different perspectives in order to optimise the design of IC programmes. The results also support the relevance of joint decision-making and coordination processes between professionals, informal caregivers and patients.

A mixed-methods systematic review of nurse-led interventions for people with multimorbidity

AIMS

To identify types of nurse-led interventions for multimorbidity and which outcomes are positively affected by them.

DESIGN

Mixed-methods systematic review following the Joanna Briggs Institute (JBI) methods for convergent-integrated reviews.

PROSPERO ID

CRD42020197956.

DATA SOURCES

Cochrane CENTRAL, CINAHL, Embase and MEDLINE were searched in October 2020. Grey literature sources included OpenGrey, the Journal of Multimorbidity and Comorbidity and reference mining.

REVIEW METHODS

English-language reports of nurse-led interventions for people with multimorbidity were included based on author consensus. Two reviewers performed independent quality appraisal using JBI tools. Data were extracted and synthesized using a pre-existing taxonomy of interventions and core outcome set.

RESULTS

Twenty studies were included, with a median summary quality score of 77.5%. Interventions were mostly case-management or transitional care interventions, with nurses in advanced practice, support to self-manage conditions, and an emphasis on continuity of care featuring frequently. Patient-centred outcomes such as quality of healthcare and health-related quality of life were mostly improved, with mixed effects on healthcare utilization, costs, mortality and other outcomes.

CONCLUSION

Interventions such as case management are agreeable to patients and transitional care interventions may have a small positive impact on healthcare utilization. Interventions include long-term patient management or short-term interventions targeted at high-risk junctures. These interventions feature nurses in advanced practice developing care plans in partnership with patients, to simplify and improve the quality of care both in the long and short-term.

IMPACT

This is the first mixed-methods review which includes all types of nurse-led interventions for multimorbidity and does not focus on specific comorbidities or elderly/frail populations. Using adapted consensus-developed frameworks for interventions and outcomes, we have identified the common features of interventions and their overall typology. We suggest these interventions are of value to patients and healthcare systems but require localization and granular evaluation of their components to maximize potential benefits.

Patterns of Comorbidity and Multimorbidity Among Patients With Multiple Sclerosis in a Large US Commercially Insured and Medicare Advantage Population

Background: Comorbidities are common in patients with multiple sclerosis (MS), thus increasing the complexity of disease management and economic burden and worsening their prognosis and quality of life. Real-world evidence comparing comorbidities and multimorbidity patterns of commercially insured vs Medicare enrollees with MS is lacking. Objective: To evaluate the patterns of comorbidity and multimorbidity among patients with MS in a US commercially insured and Medicare Advantage population. Methods: This retrospective observational cohort study was conducted using Aetna health claims data from January 1, 2015, to October 31, 2019. Eligibility criteria were (1) at least 3 MS-related inpatient/outpatient (ICD-10-CM: G35), or disease-modifying therapy claims within 1 year (date of first claim = index date); (2) Aetna commercial health plan or Medicare Advantage medical and pharmacy benefits at least 12 months pre-/post-index; and (3) age 18 and older. Commercially insured patients, Medicare Advantage patients younger than 65 years of age, and Medicare Advantage patients 65 years and older were compared. Results: Among 5000 patients (mean [SD] age, 52.6 [12.9]; 75.2% female), 53% had commercial insurance and 47% had Medicare Advantage (59.2% disabled age <65). Medicare Advantage patients were older (age <65: 53.3 [7.9]; age ≥65: 70.8 [5.2]) vs commercial (age, 45.7 [10.2]), had greater comorbidity burden (Charlson Comorbidity Index; age <65: 1.17 [1.64], age ≥65: 1.65 [1.95]) vs commercial (0.53 [1.02]) (all P < .0001). Symptoms specific to MS (ie, malaise, fatigue, depression, spasms, fibromyalgia, convulsions) were more common among patients younger than 65 (all P < .0001). Age-related and other comorbidities (ie, hypertension, hyperlipidemia, dyspepsia, osteoarthritis, osteoporosis, glaucoma, diabetes, cerebrovascular, cancer) were more common among patients 65 years and older Medicare Advantage (all P < .0001). Multiple comorbidities were highly prevalent (median, 4 comorbidities), particularly among Medicare Advantage patients younger than 65 (median, 6) and Medicare Advantage patients 65 and older (median, 7). Conclusions: Comorbidities and multimorbidity patterns differed between patients with MS with commercial insurance and patients with Medicare Advantage. Multimorbidity was highly prevalent among patients with MS and should be considered in the context of clinical decision making to ensure comprehensive MS management and improve outcomes.

Prevalent Multimorbidity Combinations Among Middle-Aged and Older Adults Seen in Community Health Centers

BACKGROUND

Multimorbidity (≥ 2 chronic diseases) is associated with greater disability and higher treatment burden, as well as difficulty coordinating self-management tasks for adults with complex multimorbidity patterns. Comparatively little work has focused on assessing multimorbidity patterns among patients seeking care in community health centers (CHCs).

OBJECTIVE

To identify and characterize prevalent multimorbidity patterns in a multi-state network of CHCs over a 5-year period.

DESIGN

A cohort study of the 2014-2019 ADVANCE multi-state CHC clinical data network. We identified the most prevalent multimorbidity combination patterns and assessed the frequency of patterns throughout a 5-year period as well as the demographic characteristics of patient panels by prevalent patterns.

PARTICIPANTS

The study included data from 838,642 patients aged ≥ 45 years who were seen in 337 CHCs across 22 states between 2014 and 2019.

MAIN MEASURES

Prevalent multimorbidity patterns of somatic, mental health, and mental-somatic combinations of 22 chronic diseases based on the U.S. Department of Health and Human Services Multiple Chronic Conditions framework: anxiety, arthritis, asthma, autism, cancer, cardiac arrhythmia, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), congestive heart failure, coronary artery disease, dementia, depression, diabetes, hepatitis, human immunodeficiency virus (HIV), hyperlipidemia, hypertension, osteoporosis, post-traumatic stress disorder (PTSD), schizophrenia, substance use disorder, and stroke.

KEY RESULTS

Multimorbidity is common among middle-aged and older patients seen in CHCs: 40% have somatic, 6% have mental health, and 24% have mental-somatic multimorbidity patterns. The most frequently occurring pattern across all years is hyperlipidemia-hypertension. The three most frequent patterns are various iterations of hyperlipidemia, hypertension, and diabetes and are consistent in rank of occurrence across all years. CKD-hyperlipidemia-hypertension and anxiety-depression are both more frequent in later study years.

CONCLUSIONS

CHCs are increasingly seeing more complex multimorbidity patterns over time; these most often involve mental health morbidity and advanced cardiometabolic-renal morbidity.

Mediterranean Diet Adherence and Risk of Depressive Symptomatology in a French Population-Based Cohort of Older Adults

Several foods from the Mediterranean Diet (MeDi) have already been characterized as beneficial for depression risk, while studies focusing on adherence to the overall MeDi are lacking among older adults at higher risk of depression. The aim of this study was to assess the association between MeDi adherence and the risk of depressive symptomatology (DS) in an older French cohort followed for 15 years. Participants from the Three-City Bordeaux cohort answered a food frequency questionnaire used to assess their MeDi adherence. The Center for Epidemiologic Studies Depression (CES-D) scale score of 16 or greater and/or use of antidepressant treatment ascertained at each visit defined incident DS. Random-effect logistic regression models were adjusted for potential confounders. Among 1018 participants, aged 75.6 years (SD 4.8 years) on average at baseline, 400 incident cases of DS were identified during the follow-up. Only when restricting the definition of DS to a CES-D score ≥ 16 was a borderline-significant trend towards a benefit of greater adherence to the MeDi with reduced odds of DS found (p-value = 0.053). In this large sample of older French adults, a potential benefit of greater adherence to the MeDi regarding the risk of DS would depend on the definition of DS.